Children are limited only by their imaginations when they pretend. Every part of their imaginary worlds - from the city streets populated by superheroes to the musty halls of crumbling castles – is left to their imagination. Grownups can pretend, too, but they often have ways of bringing their imagination to life.

Operation Bushmaster is a major field exercise where first-year medical students play the part of wounded patients for fourth-year medical students to assess and treat. Eric Singdahlsen, the external programs and hybrid simulations manager at the SimCen, trains about a dozen service member volunteers to apply moulage to the students, who take part in several injury scenarios each day.

Simple moulage application uses makeup to create superficial wounds on the body, like bruises, burns, and abrasions. Larger simulated injuries like compound fractures or amputations require more time and effort beforehand to create silicone prosthetics that must be affixed to volunteers and blended in with makeup. Most “patients” during an exercise can have a variety of small and complex moulage, which together can be very time-consuming to apply.

Betsy Weissbrod, a certified medical illustrator with the SimCen, developed these temporary tattoos that can be quickly applied to simulated patients and enhanced with makeup to create stunning moulage. These kind of tattoos are frequently used in exercises to train medical students both in the field and in a clinical setting. (Image credit: Betsy Weissbrod at the Val G. Hemming Simulation Center)

“Depending on the complexity of the injury, it can take a long time. It has to do with how much of the person’s body is being affected. I might be able to put a burn on somebody’s arm in about 10 to 15 minutes, but if they have burns over 80 percent of their body then that’s going to take a lot longer,” said Singdahlsen.

Education Coordinator Gwen Nelmes of the National Museum ofHealth and Medicine, had moulage applied by staff in the HybridSimulation Lab at the SimCen. These dark splotches representbuboes, or swollen lymph nodes, that are a common symptom ofbubonic plague. The SimCen applied moulage to several visitors tothe museum as part of the Bites event, which was an exhibit themed around different bites and the resulting rashes and effectsthat can result from them. (Image credit: Image credit: BetsyWeissbrod at the Val G. Hemming Simulation Center)

Betsy Weissbrod, a medical illustrator for the SimCen, designed a method to streamline moulage for smaller injuries through use of temporary tattoos. Weissbrod designs the injuries on the computer, then prints them out onto temporary tattoo paper that can be purchased from almost any store. This saves a lot of time not only applying the moulage, but training people to apply it as well.

“[Using tattoos] didn’t start with moulage; we started with the first-year medical students’ physical exam course. They hadn’t taken anatomy yet, and we were asking them to do a head-to-toe physical exam on a patient. They don’t necessarily know surface anatomy to the underlying anatomy they’re looking at,” Weissbrod said. “We started by painting the students themselves; physically painting on their neck where the thyroid is, or where on their chest are the heart and lungs. We quickly realized that we didn’t have the time to paint the anatomy on the number of students and the amount of time they gave to us, so we made temporary tattoos with the anatomy.”

What used to require hours of teaching and hard work can now be applied in a matter of minutes with a moist paper towel. Even with the tattoos, makeup can be used to further enhance the injuries.

Using three types of silicone, Weissbrod was able to produce moulage of an evisceration for an outside client. The scenario being tested saw two visitors to a building getting into an argument that got physical, and getting injured. One patient was stabbed in the abdomen, leading to evisceration. (Image credit: Betsy Weissbrod at the Val G. Hemming Simulation Center)

Due to their skill in moulage, the SimCen staff’s talent has been requested by other agencies within the Military Health System, including the National Museum of Health and Medicine in Silver Spring, Maryland.

“They did a Halloween-themed event for the public called ‘Bites,’ and it was about different bite wounds,” Weissbrod said. “Some folks came in to talk about animal and insect bites, and the types of rashes and bite marks associated with them, and they asked us to come in and do moulage of them on the visitors.”